Provider Demographics
NPI:1164727160
Name:COLLINS-STUCKERT, JEAN (LISAC)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:COLLINS-STUCKERT
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISAC
Mailing Address - Street 1:4545 N 36TH ST STE 121
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-3473
Mailing Address - Country:US
Mailing Address - Phone:602-402-3676
Mailing Address - Fax:602-381-3676
Practice Address - Street 1:4545 N 36TH ST STE 121
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-3473
Practice Address - Country:US
Practice Address - Phone:602-402-3676
Practice Address - Fax:602-381-3676
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10022101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)